Original Article
A clinical profile of patients with Parkinson’s disease and psychosis B. R. Amar, Ravi Yadav, Y. C. Janardhan Reddy1, Pramod Kumar Pal Departments of Neurology and 1Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India Abstract Aims: The aim of the study was to study the clinical profile of the patients with Parkinson’s disease (PD) and psychosis. Settings and Design: This was a prospective, cross sectional, hospital-based study done at the Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India from September 2009 to January 2011. All patients with PD, diagnosed by United Kingdom PD Society Brain Bank criteria, having with features of psychosis as diagnosed by the neuropsychiatric inventory (NPI) were included. Patients without a caregiver who could validate the patient’s symptoms were excluded. Results: A total of 40 patients (5 women, 35 men) with PD with psychosis (mean age: 54.2 ± 11.5 years, mean duration of illness: 6.5 ± 4.5 years, and mean duration of psychosis: 4.3 ± 4.3 years) were included in the study. The Global NPI score was 19.1 ± 11.5. Majority of the patients had pure hallucinations (85%), while the rest had either pure delusions (7.5%) or a combination of delusions and hallucinations (7.5%). In those with hallucinations, visual hallucinations were the commonest (60%) (pure only in 22.5%), followed by auditory (45%), minor hallucinations (45%), and tactile (20%). Only one person reported having olfactory hallucinations (2.5%). Loss of insight was most often observed during the visual hallucinations (52%), followed by tactile (44.4%), auditory (38.9 %), and minor hallucinations (33.3%). Conclusions: In patients with PD and psychosis, pure hallucinations are common and visual hallucinations are the commonest among the hallucinations. A large proportion of patients have minor hallucinations, which need to be recognized early for effective and early management. The limitations of the study were small sample size, use of a single scale to assess psychosis and subjective assessment of insight.
Key Words Delusions, hallucinations, NPI, PD, psychosis For correspondence: Dr. Pramod Kumar Pal, Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS),
Hosur Road, Bangalore - 560 029, Karnataka, India. E-mail: [email protected] Ann Indian Acad Neurol 2014;17:187-92
Introduction
and prognosis of the disease and are important risk factors for nursing home placement and mortality of PD.[3,4]
Parkinson’s disease (PD) is one of the commonest movement disorders in the world.[1] In spite of PD being a predominantly motor disorder, majority of patients develop a variety of non-motor manifestations. The most challenging nonmotor symptom is psychosis. The clinical spectrum of psychosis in PD includes visual hallucinations with or without retained insight, other hallucinations (auditory, tactile, olfactory, and minor hallucinatory phenomena) and delusions.[2] These psychotic symptoms have a major impact on the natural course Access this article online Quick Response Code:
Website: www.annalsofian.org
DOI: 10.4103/0972-2327.132625
The prevalence of the psychotic symptoms have varied largely in most studies, mostly owing to a lack of uniform definition of psychosis, lack of disease-specific scales to measure psychosis, and also use of scales that are not validated to measure psychotic symptoms.[5-7] In addition, there are only limited data on the pa ern of psychosis in PD, especially from India.[8] Therefore, the present study was undertaken to study the clinical profile of the patients with Parkinson’s disease and psychosis using the neuropsychiatric inventory (NPI) for rating of psychotic symptoms. Although various scales have been used to assess psychosis in PD,[9-11] the NPI is a well-validated scale to screen for various psychotic symptoms in PD.[12]
Materials and Methods This prospective, cross-sectional, hospital-based study was conducted at the Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, Annals of Indian Academy of Neurology, April-June 2014, Vol 17, Issue 2
188
Amar, et al.: Psychosis in PD
India from September 2009 to January 2011. The study was approved by the institute’s ethics commi ee and all the patients and their caregivers who were interviewed gave written informed consent. A diagnosis of PD was made according to the United Kingdom PD Society (UKPDS) Brain Bank criteria for PD[13] and all patients were evaluated by the UPDRS-part III (motor part) scale,[13] Hoehn and Yahr staging, the NPI,[12] the mini mental status examination (MMSE) score for cognitive screening.
Results
The NPI evaluates 12 neuropsychiatric domains: delusions, hallucinations, agitation, depression, anxiety, apathy, irritability, euphoria, disinhibition, aberrant night time behavior, night time behavior, and appetite change. The frequency, severity, and distress of each domain is rated on the basis of scripted questions administered to the patient’s caregiver. The product of frequency and severity of each domain and the total NPI score was calculated in all patients. The test-retest variability, interrater variability has been already established.[12] The patients were diagnosed to have psychosis based on diagnostic criteria for psychosis in PD.[14] The diagnosis of PD associated psychosis was made in a case of PD with symptoms starting a er the onset of PD with the presence of at least one of the following symptoms (1) illusions, (2) false sense of presence, (3) hallucinations, and (4) delusions. The symptoms should last for at least 1 month and the other mimickers should be excluded.[14] The patients who were excluded were those as per UKPDS brain bank criteria, those who were unwilling to participate in the study or did not cooperate for the interview and those without a caregiver who could validate the history of patient’s symptoms. The patients with cognitive deficits were not excluded.
Characteristics of psychosis The mean duration of psychotic symptoms (hallucinations/ delusions) was 4.34 ± 4.26 years. The psychotic symptoms included pure hallucinations in 34 patients (85%), pure delusions in 3 patients (7.5%), and a combination of delusions and hallucinations in 3 patients (7.5%) [Tables 3-6]. Visual hallucinations were the commonest type of hallucinations, followed by other hallucinations, such as auditory, minor, tactile, and olfactory [Table 5]. Majority of the patients had a mixed type of hallucinations (45%). Nine (22.5%) had pure visual hallucinations, five (12.5%) had pure auditory, and only two patients (5%) had minor hallucinations. A combination
A predesigned proforma was used to record comprehensively all the information pertaining to PD and the psychotic symptoms. Hallucinations, when present, were classified into visual, auditory, tactile, olfactory, minor, or mixed. Further characterization of hallucinations included frequency, threatening or nonthreatening, presence or absence of insight, time of occurrence, and so on. All effort was made to collect accurate information of the past and current medications for Parkinsonian symptoms as well for other disorders, if any. Details of anti-Parkinsonian drugs, especially dosage, duration of treatment, and temporal association between medications and onset of psychosis were ascertained. The total levodopa equivalent dosage (TLED) was calculated a er converting all drug dosages patients were currently taking into their levodopa equivalent dosages.[15] These were then added up and the mean TLED calculated. Statistical analysis Statistical analysis was done using SPSS 16.0 package. Data were expressed using descriptive statistics, that is, mean, standard deviation (SD) for continuous variables and frequency, percentages for categorical variables. Comparisons between groups were done using independent Student’s t-test for continuous variables and chi-square test for categorical variables. Correlation between continuous variables was done using Pearson’s correlation coefficient. A P < 0.05 was considered statistically significant. Annals of Indian Academy of Neurology, April-June 2014, Vol 17, Issue 2
A total of 40 patients were recruited for this study. The mean TLED was 683.36 ± 404.33 mg/day [Table 1]. Majority of the patients had prior use of anticholinergics (62.5%), followed by use of dopamine agonists (47.5%), levodopa (35%), and amantadine (35%). Approximately, 15% of patients had prior exposure to antipsychotics [Table 2]. Six patients had an MMSE
A clinical profile of patients with Parkinson’s disease and psychosis B. R. Amar, Ravi Yadav, Y. C. Janardhan Reddy1, Pramod Kumar Pal Departments of Neurology and 1Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India Abstract Aims: The aim of the study was to study the clinical profile of the patients with Parkinson’s disease (PD) and psychosis. Settings and Design: This was a prospective, cross sectional, hospital-based study done at the Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India from September 2009 to January 2011. All patients with PD, diagnosed by United Kingdom PD Society Brain Bank criteria, having with features of psychosis as diagnosed by the neuropsychiatric inventory (NPI) were included. Patients without a caregiver who could validate the patient’s symptoms were excluded. Results: A total of 40 patients (5 women, 35 men) with PD with psychosis (mean age: 54.2 ± 11.5 years, mean duration of illness: 6.5 ± 4.5 years, and mean duration of psychosis: 4.3 ± 4.3 years) were included in the study. The Global NPI score was 19.1 ± 11.5. Majority of the patients had pure hallucinations (85%), while the rest had either pure delusions (7.5%) or a combination of delusions and hallucinations (7.5%). In those with hallucinations, visual hallucinations were the commonest (60%) (pure only in 22.5%), followed by auditory (45%), minor hallucinations (45%), and tactile (20%). Only one person reported having olfactory hallucinations (2.5%). Loss of insight was most often observed during the visual hallucinations (52%), followed by tactile (44.4%), auditory (38.9 %), and minor hallucinations (33.3%). Conclusions: In patients with PD and psychosis, pure hallucinations are common and visual hallucinations are the commonest among the hallucinations. A large proportion of patients have minor hallucinations, which need to be recognized early for effective and early management. The limitations of the study were small sample size, use of a single scale to assess psychosis and subjective assessment of insight.
Key Words Delusions, hallucinations, NPI, PD, psychosis For correspondence: Dr. Pramod Kumar Pal, Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS),
Hosur Road, Bangalore - 560 029, Karnataka, India. E-mail: [email protected] Ann Indian Acad Neurol 2014;17:187-92
Introduction
and prognosis of the disease and are important risk factors for nursing home placement and mortality of PD.[3,4]
Parkinson’s disease (PD) is one of the commonest movement disorders in the world.[1] In spite of PD being a predominantly motor disorder, majority of patients develop a variety of non-motor manifestations. The most challenging nonmotor symptom is psychosis. The clinical spectrum of psychosis in PD includes visual hallucinations with or without retained insight, other hallucinations (auditory, tactile, olfactory, and minor hallucinatory phenomena) and delusions.[2] These psychotic symptoms have a major impact on the natural course Access this article online Quick Response Code:
Website: www.annalsofian.org
DOI: 10.4103/0972-2327.132625
The prevalence of the psychotic symptoms have varied largely in most studies, mostly owing to a lack of uniform definition of psychosis, lack of disease-specific scales to measure psychosis, and also use of scales that are not validated to measure psychotic symptoms.[5-7] In addition, there are only limited data on the pa ern of psychosis in PD, especially from India.[8] Therefore, the present study was undertaken to study the clinical profile of the patients with Parkinson’s disease and psychosis using the neuropsychiatric inventory (NPI) for rating of psychotic symptoms. Although various scales have been used to assess psychosis in PD,[9-11] the NPI is a well-validated scale to screen for various psychotic symptoms in PD.[12]
Materials and Methods This prospective, cross-sectional, hospital-based study was conducted at the Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, Annals of Indian Academy of Neurology, April-June 2014, Vol 17, Issue 2
188
Amar, et al.: Psychosis in PD
India from September 2009 to January 2011. The study was approved by the institute’s ethics commi ee and all the patients and their caregivers who were interviewed gave written informed consent. A diagnosis of PD was made according to the United Kingdom PD Society (UKPDS) Brain Bank criteria for PD[13] and all patients were evaluated by the UPDRS-part III (motor part) scale,[13] Hoehn and Yahr staging, the NPI,[12] the mini mental status examination (MMSE) score for cognitive screening.
Results
The NPI evaluates 12 neuropsychiatric domains: delusions, hallucinations, agitation, depression, anxiety, apathy, irritability, euphoria, disinhibition, aberrant night time behavior, night time behavior, and appetite change. The frequency, severity, and distress of each domain is rated on the basis of scripted questions administered to the patient’s caregiver. The product of frequency and severity of each domain and the total NPI score was calculated in all patients. The test-retest variability, interrater variability has been already established.[12] The patients were diagnosed to have psychosis based on diagnostic criteria for psychosis in PD.[14] The diagnosis of PD associated psychosis was made in a case of PD with symptoms starting a er the onset of PD with the presence of at least one of the following symptoms (1) illusions, (2) false sense of presence, (3) hallucinations, and (4) delusions. The symptoms should last for at least 1 month and the other mimickers should be excluded.[14] The patients who were excluded were those as per UKPDS brain bank criteria, those who were unwilling to participate in the study or did not cooperate for the interview and those without a caregiver who could validate the history of patient’s symptoms. The patients with cognitive deficits were not excluded.
Characteristics of psychosis The mean duration of psychotic symptoms (hallucinations/ delusions) was 4.34 ± 4.26 years. The psychotic symptoms included pure hallucinations in 34 patients (85%), pure delusions in 3 patients (7.5%), and a combination of delusions and hallucinations in 3 patients (7.5%) [Tables 3-6]. Visual hallucinations were the commonest type of hallucinations, followed by other hallucinations, such as auditory, minor, tactile, and olfactory [Table 5]. Majority of the patients had a mixed type of hallucinations (45%). Nine (22.5%) had pure visual hallucinations, five (12.5%) had pure auditory, and only two patients (5%) had minor hallucinations. A combination
A predesigned proforma was used to record comprehensively all the information pertaining to PD and the psychotic symptoms. Hallucinations, when present, were classified into visual, auditory, tactile, olfactory, minor, or mixed. Further characterization of hallucinations included frequency, threatening or nonthreatening, presence or absence of insight, time of occurrence, and so on. All effort was made to collect accurate information of the past and current medications for Parkinsonian symptoms as well for other disorders, if any. Details of anti-Parkinsonian drugs, especially dosage, duration of treatment, and temporal association between medications and onset of psychosis were ascertained. The total levodopa equivalent dosage (TLED) was calculated a er converting all drug dosages patients were currently taking into their levodopa equivalent dosages.[15] These were then added up and the mean TLED calculated. Statistical analysis Statistical analysis was done using SPSS 16.0 package. Data were expressed using descriptive statistics, that is, mean, standard deviation (SD) for continuous variables and frequency, percentages for categorical variables. Comparisons between groups were done using independent Student’s t-test for continuous variables and chi-square test for categorical variables. Correlation between continuous variables was done using Pearson’s correlation coefficient. A P < 0.05 was considered statistically significant. Annals of Indian Academy of Neurology, April-June 2014, Vol 17, Issue 2
A total of 40 patients were recruited for this study. The mean TLED was 683.36 ± 404.33 mg/day [Table 1]. Majority of the patients had prior use of anticholinergics (62.5%), followed by use of dopamine agonists (47.5%), levodopa (35%), and amantadine (35%). Approximately, 15% of patients had prior exposure to antipsychotics [Table 2]. Six patients had an MMSE
